A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect?
Diplopia.
Masklike expression.
Twitching of the face.
Agitation.
The Correct Answer is A
Answer: A. Diplopia.
Rationale:
A) Diplopia: Diplopia, or double vision, is a common symptom in multiple sclerosis (MS) due to demyelination of nerves in the brainstem, affecting eye movement coordination. This visual disturbance is frequently seen in MS clients and may worsen during flare-ups.
B) Masklike expression: A masklike expression is more commonly associated with Parkinson’s disease rather than multiple sclerosis. This characteristic facial appearance is due to muscle rigidity, which is not typically a manifestation of MS.
C) Twitching of the face: Facial twitching, or fasciculations, is not typically a primary symptom of multiple sclerosis. While muscle weakness and spasticity are common in MS, twitching is more commonly seen in conditions such as amyotrophic lateral sclerosis (ALS).
D) Agitation: Agitation is not a primary symptom of MS. While MS can lead to cognitive changes or mood disturbances, such as depression, severe agitation is more commonly linked with other neurological or psychiatric conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.
Correct Answer is A
Explanation
Choice A rationale:
The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.
Choice B rationale:
Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.
Choice C rationale:
Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.
Choice D rationale:
Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.
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